Neurological Associates of Washington PLLC
Authorization for Neurological Associates of Washington
to Use or Disclose My Health Care Information
Please provide the following:
Name
(Last, First, M.I.):
,
Previous Name(Last, First, M.I.)::
,
Date of Birth:
,
,
I. My Authorization
You may use or disclose the following healthcare information (Check all that apply):
 All health care information in my medical record
 Health care information in my medical record relating to the following treatment or condition:
 Health care information in my medical record for the date(s):
 Other (e.g., X rays, bills), specify date(s):
You may use or disclose health care information regarding testing, diagnosis, and treatment for (check all that apply):
 HIV (AIDS virus)
 Sexually transmitted disease
 Drug and/or alcohol use
 Psychiatric disorders/mental health
You may disclose this health care information to:
Name (or title) and organization:
Address:
City:
State:
Zip:
Reason(s) for this authorization (check all that apply):
 At my request
 Other (specify):
 Check only if Neurological Associates of Washington PLLC requests the authorization for marketing purposes
 Check only if Neurological Associates of Washington PLLC will be paid or get something of value for providing
health information for marketing purposes
 This authorization ends: (This document does not permit disclosure of health information created more than 90 days
after the date signed.)
 In 90 days from the date signed
 When the following date occurs:
 on (date):
I. My Rights
I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or
enrollment). However, I do have to sign an authorization form:
1. To take part in a research study or
2. To receive health care when the purpose is to create health care information for a third party.
I may revoke this authorization in writing. If I did, it would not affect any actions already taken by Neurological
Associates of Washington PLLC based upon this authorization. I may not be able to revoke this authorization if its purpose
was to obtain insurance. Two ways to revoke this authorization are as follows:
1. Fill out revocation form. A form is available from Neurological Associates of Washington PLLC. Or
2. Write a letter to Neurological Associates of Washington PLLC.
Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may
no longer protect it.
______________________________________________________________________________________
Patient or Legally Authorized individual signature
Date
Time
________________________________________________________________________
Printed Name if signed on behalf of the patient
Relationship (parent, legal guardian, personal representative)
IPS-102.2: Notice of Privacy Practices: Acknowledgement
Patient Information Privacy and Security Manual
Neurological Associates of Washington PLLC